Registration Form Badger Youth Baseball/Softball P. O. Box 369, Kinsman, oh 44428

Registrations are for boys and girls ages 5-14 years old and the costs are: $50 per player, $35 for T-Ball, or $100 total max fee for one family. PLEASE BRING PHOTO COPY OF PLAYER’S BIRTH CERTIFICATE IF NOT ON FILE.

Player _____________________ ______________________ ____Boy ____Girl ____New Player

Father _____________________ ______________________ ____Address same as Player

Mother_____________________ ______________________ ____Address same as Player

Player Address Mother/Father Address (if different than Player)

Street _______________________________________ Street ____________________________________

City, State & Zip _______________________________ City, State & Zip ____________________________

Telephone & Contact Information:

Home: _____________________________________ Work: __________________________________

Mother Cell: _________________________________ Father Cell: ______________________________

e-mail address:_____________________________________________________________________________

Volunteer Information (please indicate any/all areas you would be interested in helping with): ____ Officer ____ Manage/Coach ____Assistant Manager/Coach ____ Field Maintenance ____Other, as needed (uniforms, equipment, fundraising, etc.)

Birth Date (mm/dd/yyyy) ____________________ Player’s Age on June 1, 2017 ___________

Birth Certificate: ______Attached ______On File Shirt Size (circle one): Youth: S M L Adult: S M L XL

Comments: _______________________________________________________________________________

_______________________________________________________________________________

MEDICAL HISTORY

As stated in Section 3313.712 of the Ohio Revised Code, this medical history should be completed by the parent/guardian to authorize the provision of emergency treatment for Children who become ill or injured while under authority, when parent/guardian cannot be reached for the purpose of giving consent for such treatment. Such authority is necessary to overcome legal obstacles to the provisions of such treatment when all reasonable attempts to reach the parent/guardian have failed.

History Of Epilepsy/Convulsions: ______ Yes ______ No Immunization Up To Date ______Yes ______No

Medications Child is taking:_____________________________________________ Date Of Last Tetanus Shot: ___________________

Previous Injuries? (broken bones, head Injuries, etc.): ___________________________________________________________________

Doctor Name & Phone: ___________________________________________________________________________________________

Dentist Name & Phone: ___________________________________________________________________________________________

If the above cannot be reached, permission is given to have emergency care given by any available licensed physician, dentist, or specialist.

(Initial one) Yes _________ No _________

Preferred Hospital & Phone: __________________________________________________________________________________________

If accident occurs at an away game, permission is given to transport to nearest hospital for treatment.

(Initial one) Yes ___________ No ___________

Relative/Neighbor to Notify in Case of Emergency & Phone: ________________________________________________________________

I am the parent or legal guardian of the above named Child, who wishes to participate in the baseball/softball activities organized by Badger Hot Stove and Hartford Optimist. I believe that my Child is in good health and that there is no health or medical reason why my Child cannot or should not participate in strenuous physical activity. I understand that it is my responsibility to have my Child examined and cleared for participation in sporting activities, and I agree that Badger Hot Stove/Hartford Optimist has no duty to ascertain my Child’s health or physical limitations or conditions. I also understand that all sports including baseball/softball involve the risk of injury, and I agree to assume the risk of injury to my Child or to me resulting from my Child’s participation in this program. In exchange for Badger Hot Stove/Hartford Optimist allowing my Child to participate in it’s activities, I hereby waive and release all claims that my Child or I may have or claim to have arising out of my Child’s participation in all activities associated with Badger Hot Stove/Hartford Optimist. This waiver and release extends to not only Badger Hot Stove/Hartford Optimist, but also to it’s 1) affiliated organization; 2) team sponsor; 3) employees or volunteers (Including without limitation managers, coaches, assistants and umpires); 4) officers, directors and board members; and 5) owners or occupiers of land upon which activities may take place.